DECLARATION OF COMPLIANCE WITH SUSTAINABILITY CRITERIA
according to the Part D Annex 4 Government Regulation No. 351/2012 on sustainability criteria for biofuels 
Unique identification number of the declaration:           
Issuer:       
     	Recipient:                  
     	Authorized person:                
     	
1. Information about biofuels:
Type of biofuels including feedstock:                     
Quantity (t or m3):                      
Country of biomass origin:                    
The biofuels have been produced from waste or residues whit origin other than from agricultural, forestry, aquaculture, and fisheries.	  yes	  no 
Biofuels have been produced in an installation that was in operation prior to 24 January 2008.                                                                                                                                                                       yes                                 	  no	
2. The greenhouse gas emissions production:
The greenhouse gas emissions production (gCO2ekv/MJ):                    
The greenhouse gas emissions production has been determined using:
 default values laid down in Part A of Annex 1 Government Regulation
 actual values calculated in accordance with methodology laid down in Part B of Annex 1 Government Regulation
 combination of actual values with disaggregated default value laid down in Part C of Annex 1 Government Regulation 
 bonus for growing biomass on deteriorated land according to Point 7 of Part B Annex 1 Government Regulation has been used 
 bonus for using improved agricultural procedures according to point 1 part B annex 1   Government Regulation has been used4
Transportation means and distance:                       	

                      
-------------------------------                                                                   --------------------------------
  Place and date of issue                                                                              Signature